Provider Demographics
NPI:1467838847
Name:SOLOMON PORCH LLC
Entity type:Organization
Organization Name:SOLOMON PORCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, PSYD
Authorized Official - Phone:907-350-4353
Mailing Address - Street 1:626 2ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3466
Mailing Address - Country:US
Mailing Address - Phone:907-350-4353
Mailing Address - Fax:
Practice Address - Street 1:626 2ND ST STE 101
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3466
Practice Address - Country:US
Practice Address - Phone:907-350-4353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK10031301OtherALASKA ENTITY